Table 5.
Prophylaxis for herpes group virusesa
| CMV universal antiviral prophylaxisa | ||
|---|---|---|
| CMV serologic status ± antilymphocyte-globulin-induction therapy (ALG) | Prophylaxis | Monitoring (antigenemia) |
| D+/R− no ALG | Intravenous ganciclovir 5 mg/kg iv (loading dose) then po valganciclovir (900 mg/d corrected for renal function) or po ganciclovir (3 gm/d)c × 3 mo | Monthly for 6 mo after discontinuation of therapyb |
| D+ or R+ with ALG | Intravenous ganciclovir 5 mg/kg iv for first dose then either per renal function to discharge or switch to po valganciclovir (900 mg/d corrected for renal function) or po ganciclovir (3 gm/d)c × 6 mo | Monthly for 6 mo after discontinuation of therapyb |
| D−/R+ no ALG | Oral valganciclovir (900 mg/d corrected for renal function) × 3 mo | Symptoms only |
| D−/R− | Oral famciclovir 500 mg po qd × 3–4 mo (or valacyclovir 500 bid or acyclovir 400 tid). Use of CMV-negative or leukocyte-filtered blood | Symptoms, fever/neutropenia |
| Status unknown with ALG | Intravenous ganciclovir 5 mg/kg iv for first dose and QD (corrected for renal function) until sero-status determined. | As above |
The human herpes viruses are among the most important causes of infectious disease morbidity and mortality in the transplant recipient. Preventative regimens are determined by the clinical risk, the major determinants of which are the past experience of donor and recipient with the virus (as defined by the presence or absence of circulating antibody before transplant) and the nature of the immunosuppressive therapy. The dose of antiviral therapies are not, in general, reduced for neutropenia.
aPreemptive therapy: Preemptive therapy requires a carefully organized monitoring program and patient compliance. Either a molecular CMV viral load test or a pp65 antigenemia assay may be used for monitoring. Monitoring should be performed once weekly after transplantation for 12–24 wk. Infections indicated by positive assays are treated with either oral valganciclovir (900 mg 2 times a day) or intravenous ganciclovir (5 mg/kg 2 times a day). Full doses are used for loading after which dosing is corrected for renal function. Therapy is continued until viremia is undetectable. Mixed prophylaxis: Many centers prefer universal prophylaxis for highest risk recipients (D+/R− or R+ with lymphocyte depletion) and preemptive therapy for other groups.
bALG: Antilymphocyte antibodies include any of the lytic, lymphocyte-depleting antibody preparations.
cValacyclovir (8 gm/d) has been used as an alternative agent in renal transplant recipients.